Comparison of clinical outcomes between arthroscopic debridement and conservative treatment of primary adhesive capsulitis of the hip.

PURPOSE: The purpose of this study was to assess the clinical outcomes and change of ROM between patients with adhesive capsulitis of the hip (ACH) who underwent arthroscopic treatment and those who underwent conservative treatment at a minimum follow-up of two years. METHODS: From 2010 to 2017, 35 hips (32 patients, 10 men and 22 women) diagnosed with primary ACH were enrolled and followed up for a minimum of two years. Arthroscopic surgery was performed in 17 patients (20 hips, operation group), and conservative treatment was performed in 15 patients (15 hips, control group). Outcomes were measured with the visual analogue scale (VAS), University of California, Los Angeles (UCLA) activity scale, modified Harris hip score (mHHS), and degree of range of motion (ROM). RESULTS: The patients in the operation group were younger than those in the control group (mean age, 36.6 vs 46.2, p = 0.032). The VAS scores were significantly lower in the operation group than in the control group at two weeks, six weeks, and 24 months of follow-up. Moreover, the operation group showed a trend of better values of UCLA and mHHS, with no statistical differences during the entire follow-up; these patients also achieved greater improvements of external rotation at six weeks' evaluation. CONCLUSION: The patients with ACH in the two groups shows improvement of pain, UCLA scale, mHHS, and ROM at a minimum two year follow-up. Based on this study, we do not routinely recommend surgical treatment. However, patients with intractable pain and severe limitation of ROM are possible candidate of arthroscopic capsular release.

The Optimal Time of Postoperative Feeding After Total Hip Arthroplasty: A Prospective, Randomized, Controlled Trial.

Whether early postoperative feeding (EPF) after total hip arthroplasty (THA) interferes with recovery of gastrointestinal motility is unclear. This randomized controlled trial compared the feasibility and patient tolerance to either EPF (at 4 hr postoperatively) or late postoperative feeding (LPF; ⩾8 hr postoperatively). One hundred forty patients were randomized to EPF (70 hips) or LPF (70 hips). Patient characteristics, surgical technique, intraoperative characteristics, and postoperative managements were similar between two groups. No significant differences were evident between the groups for vomiting (p = .231), nausea (p = .711), regain of appetite (p = .711), amount of diet (p = .630), type of food (p = .429), abdominal pain (p = 1.000), time to passage of flatus (p = .231), time to defecations (p = .619), development of postoperative ileus (p = 1.000), and length of hospital stay (p = .643). EPF and LPF show no difference in nausea, return of bowel function, and length of hospital stay without increasing postoperative morbidity. EPF can begin about 4 hr later after elective THA.

Accuracy of Magnetic Resonance Imaging and Computed Tomography Arthrography in Diagnosing Acetabular Labral Tears and Chondral Lesions.

BACKGROUND: We investigated sensitivity, specificity, and accuracy of magnetic resonance imaging (MRI) and computed tomography arthrography (CTA), on the basis of arthroscopic findings, to diagnose acetabular labral tears and chondral lesions. METHODS: We retrospectively reviewed the results of MRI and subsequent CTA in 36 hips that underwent arthroscopic surgery (33 patients; 17 males [17 hips] and 16 females [19 hips]; average age, 35 years). All patients had positive impingement test results and groin pain. We analyzed sensitivity, specificity, and accuracy of MRI and CTA by comparing with the arthroscopic findings. Interobserver agreement and intraobserver reproducibility of the presence of tears and cartilage lesions on MRI and CTA were calculated using Kappa coefficients. RESULTS: The sensitivity, specificity, and accuracy of MRI for detection of acetabular labral tears by two observers were 60%, 80%, and 64%, respectively, and 65%, 70%, and 69%, respectively. The sensitivity, specificity, and accuracy of CTA for detection of labral tears by both observers were 85%, 90%, and 86%, respectively, and 92%, 80%, and 89%, respectively. However, the sensitivity and specificity of MRI for detection of acetabular chondral lesions by both observers were 36% and 84%, respectively, and 46% and 88%, respectively. The sensitivity and specificity of CTA for detecting acetabular cartilage lesions by both observers were 46% and 72%, respectively, and 64% and 72%, respectively. Intraobserver reproducibility for detection of labral tears and chondral lesions by using MRI was substantial (κ = 0.756 and κ = 0.693, respectively). Interobserver reliability for detection of labral tears and chondral lesions by using MRI was substantial (κ = 0.700 and κ = 0.875, respectively). Intraobserver reproducibility for detection of labral tears and chondral lesions by using CTA was substantial (κ = 0.832 and κ = 0.774, respectively). Interobserver reliability for detection of labral tears and chondral lesions by using CTA was high (κ = 0.886 and κ = 0.596, respectively). CONCLUSIONS: This study demonstrated that the accuracy of MRI to detect an acetabular labral tear and a chondral lesion of the hip joint was not sufficient. CTA was reliable in the diagnosis of acetabular labral tears. However, both CTA and MRI were also of limited value to detect chondral lesions.

Mortality and its risk factors in nonagenarians after hip fractures.

BACKGROUND: The purpose of this study was to assess mortality with a minimum of 2-year follow-up, related risk factors for mortality, and functional outcomes after surgical interventions in nonagenarian patients with hip fractures at the latest follow up. METHODS: Between June 2003 and November 2015, 260 nonagenarians (271 hips) with femoral neck and intertrochanteric fractures were included in this retrospective study. Cumulative mortality using the Kaplan-Meier method and risk factors for mortality using Cox proportional-hazards regression model were estimated. As functional outcome, ambulatory ability was assessed before injury and at the latest follow-up. RESULTS: Six-teen patients (16 hips) were lost to follow-up. The mean age at the time of surgery was 92.2 years (range 90-108 years). Mortality rates were 23.4% (57 of 244 patients) at 1 year and 40.6% (99 of 244 patients) at 2 years. Both genders had elevated standardized mortality ratio at 2-year post-fracture compared to that a 1-year post fracture. Multivariate analysis showed that American Society of Anesthesiologists (OR, 1.371; 95% CI, 1.021-1.843; P = 0.036) and time interval from trauma to operation (OR, 1.043; 95% CI, 1.002-1.086; P = 0.039) were significantly associated with risk of mortality. Of 58 patients alive, 13 patients (22.4%) had the same ambulatory ability before and after injury. CONCLUSIONS: This study demonstrates that mortality is higher in nonagenarians with hip fracture. Risk factors for mortality in nonagenarians with hip fracture are American Society of Anesthesiologists and time interval from trauma to operation. And, nonagenarians with hip fractures have lower rate of maintaining pre-injury ambulatory ability.

What is the most accurate radiographic criterion to determine anterior cervical fusion?

BACKGROUND CONTEXT: The accuracy of radiographic criteria for determining anterior cervical fusion remains controversial, and inconsistency in the literature makes a comparison of published clinical results problematic. The descriptions of bridging bone are still lacking and subjective, and the interpretation of images can be influenced by the type of graft or cage used. PURPOSE: To assess and validate the diagnostic accuracies of four radiographic fusion criteria using the results of surgical exploration. STUDY DESIGN: Retrospective, radiographic, and comparative study. PATIENT SAMPLE: This study included patients who required anterior or posterior exploration of a previous anterior cervical arthrodesis level(s) ranging from C3-C4 to C7-T1 for suspected pseudarthrosis or adjacent-segment pathologies. They underwent radiologic examinations to determine the four fusion criteria. We included patients whose images were taken at least 1 year after the index surgery, and 82 patients with 151 cervical segments were enrolled. OUTCOME MEASURES: The inter- and intra-rater reliabilities and validity that correlated with the results of surgical exploration for the four fusion criteria were assessed using data (fusion or not) that were collected by two raters. METHODS: The four published radiographic fusion criteria were interspinous motion (ISM) < 1 mm and superjacent ISM ≥ 4 mm, seen on dynamic radiographs; conventional bridging bone, as seen on computed tomography (CT) scans; and extra-graft bridging bone (ExGBB) and intragraft bridging bone (InGBB), observed on multi-axial reconstructed CT scans. The criteria were evaluated by two raters (spine surgeons with 5 and 7 years of experience). The raters evaluated each criterion twice at two different time points, 3 to 4 weeks apart. First, ISM and conventional bridging bone on CT scans were evaluated, followed by ExGBB and InGBB, with a time interval of 4 months. This Research was supported by the Chung-Ang University Research Grants (less than 5,000 US dollars) in 2016. RESULTS: The inter- and intra-rater reliability values of the ExGBB (0.887-0.933) criteria were the highest, followed by those for the ISM (0.860-0.906), bridging bone (0.755-0.907), and InGBB (0.656-0.695) criteria. The validity values that correlated with the exploration results were the highest for the ExGBB criteria (k=0.889), followed by the ISM (k=0.776), bridging bone (k=0.757), and InGBB (k=0.656) criteria and ExGBB showed the highest sensitivity (91.7%) and specificity (98.4%). Regarding the graft materials that were used, all criteria had the highest values in the auto-cortical group and lowest values in the cage group. Of note, sensitivity and specificity of ExGBB were 100% in autocortical group. In the cage group, the validity values for the ExGBB (k=0.663) and ISM (k=0.666) criteria were higher than those for the bridging bone (k=0.504) and InGBB (k=0.308) criteria CONCLUSION: The presence of ExGBB (anterior, posterior, or lateral to the graft or cage) correlated the best with surgical exploration. The ISM criteria demonstrated a similar accuracy to that of conventional bridging bone criteria on CT scans. In arthrodesed segments with auto-cortical bone, criteria showed the highest validity values. In cage group, ISM and ExGBB had acceptable accuracy, but the conventional bridging bone and InGBB were worse than guessing. We recommend that ISM and ExGBB criteria should be used to increase accuracy in patients who undergo arthrodesis with cages.

Arthroscopic treatment of symptomatic calcific periarthritis on the medial side of the knee after posterior cruciate ligament reconstruction: Case report and literature review.

Calcific periarthritis in the distal femur is a rare condition. Forty two year old Asian male visited to the outpatient clinic of orthopedic department with acute excruciating knee pain. The arthroscopic posterior cruciate ligament (PCL) reconstruction was performed 20 years ago with the bonepatellar tendon-bone (BPTB) autograft combined with Trevira (polyethylene terephthalate) artificial ligament. Severe tenderness was noted incidentally over the medial epicondyle area of the distal femur which the cancellous screw was inserted for PCL reconstruction, without any preceding trauma history or medial joint line tenderness due to degenerative change. The poorly defined calcific deposition was found in plain radiograph. The arthroscopic debridement of the calcification and screw removal from the distal femur was performed due to resist to conservative treatment with analgesics. After operation, the symptoms were resolved completely. The arthroscopic debridement of calcific periarthritis should be considered in specific cases, such as refractory cases with conservative management during 4-6 weeks. We present the arthroscopic treatment of the symptomatic calcific periarthritis on distal femur after PCL reconstruction can be effective.

Clinical outcomes after arthroscopic acetabular labral repair using knot-tying or knotless suture technique.

BACKGROUND: The purpose of the study was to compare the clinical results of arthroscopic labral repair using knot-tying and knotless suture anchor techniques for patients with labral tears. METHODS: From September 2012 to May 2013, we performed a randomized, prospective analysis of 40 hips with labral tears treated with arthroscopic labral repair via knot-tying (group A) or knotless suture anchors (group B). A total of 33 patients were treated for labral tears, and 7 of them received bilateral labral repair. Outcomes and intraoperative parameters were prospectively measured with the UCLA score, the modified Harris Hip Score (MHHS), the Hip disability and Osteoarthritis Outcome Score (HOOS), and the Hip Outcome Score (HOS). RESULTS: Three patients (3 hips) were lost to follow up. A total of 37 hips (30 patients) were finally analyzed: 19 hips in group A and 18 in group B. The mean traction time for group A and group B was 72.2 versus 68.7 min, respectively (p = 0.314). Although the clinical outcome scores in both groups improved between the initial and final visits, there was no difference in measurements parameters between the two groups. Survival rate, using reoperation or progression of osteoarthritis as the primary end points, was 100 %. 83 % of cases had excellent and good MHHS scores after 2 years of follow-up. During arthroscopic surgery, the drill penetrated the closing subchondral area or the joint in three hips. There was no progression of arthritic change at the latest follow-up. CONCLUSIONS: Labral repair with either knot-tying or knotless suture anchor resulted in significant postoperative improvements and no difference between the two groups after 2 years of follow-up.

No difference in clinical and radiologic outcomes after total knee arthroplasty with a new ultra-congruent mobile bearing system and rotating platform mobile bearing systems after minimum 5-year follow-up.

We retrospectively compared the clinical and radiographic results between 76 primary total knee arthroplasties (TKAs) using the e.motion Ultra-Congruent prosthesis and 155 primary TKAs using the Low Contact Stress rotating platform. All patients had a minimum 5-year follow-up. Range of motion, Hospital for Special Surgery score, Knee Society Knee Score and Knee Society Functional Score significantly increased in both groups postoperatively, but there was no significant difference between the two groups. The mechanical femorotibial angle improved in both groups postoperatively. Coronal and sagittal component angles were well maintained at the final follow-up. This study demonstrates that a new mobile-bearing prosthesis, designed to be highly congruent with a rotating bearing, could be considered with theoretical advantages and comparable outcomes of established mobile-bearing prostheses.

Diagnostic value of ultrasound and computed tomographic arthrography in diagnosing anterosuperior acetabular labral tears.

PURPOSE: This study investigated the sensitivity, specificity, and accuracy of ultrasound as well as the computed tomography arthrography (CTA) findings and arthroscopic findings for the diagnosis of anterosuperior acetabular tear and correlated tear types using the Lage classification system on ultrasound and CTA compared with the arthroscopic findings. METHODS: We retrospectively reviewed the results of ultrasonographic examinations conducted before injection and after injection of contrast for subsequent CTA in 36 hips (34 patients; 24 men [71%] and 10 women [29%]; mean age, 36 years). All patients had chronic groin pain and a positive impingement test. We analyzed the sensitivity, specificity, and accuracy before injection, after injection, and at CTA and compared these with findings with the arthroscopic findings. Interobserver agreement and intraobserver reproducibility of the presence of a tear and tear type in the anterosuperior quadrant of the acetabular labrum on ultrasonography and CTA were calculated by use of κ coefficients. RESULTS: The sensitivity, specificity, and accuracy for sonographic detection of labral tear before injection/after injection were 58%/79%, 67%/58%, and 61%/72%, respectively, for observer 1 and 75%/92%, 25%/42%, and 58%/75%, respectively, for observer 2. The sensitivity, specificity, and accuracy for CTA detection of labral tears were 96%, 92%, and 94%, respectively, for observer 1 and 88%, 92%, and 89%, respectively, for observer 2. When the sonographic classification was compared with the arthroscopic findings of observer 1 and observer 2, the accuracy before injection/after injection was only 53%/67% and 58%/75%, respectively. The accuracy of morphologic classification of CTA and arthroscopic findings of observer 1 and observer 2 was 83% and 75%, respectively. Interobserver correlation before injection and at CTA was poor (κ = 0.056) and moderate (κ = 0.642), respectively. CONCLUSIONS: Although intra-articular injection during sonographic examination could improve diagnosis of labral tears, sonographic examination as a diagnostic technique is still of limited use. However, CTA shows reliable validity in the diagnosis of acetabular labral tears. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study.

BACKGROUND: Appropriate pain management affects outcome after hip fracture surgery. Although multimodal pain management is commonly used for pain control for patients undergoing elective surgery, few studies have evaluated its use in those undergoing hip fracture surgery. This prospective randomized study was designed to determine the clinical value of multimodal pain management with preemptive pain medication and intraoperative periarticular multimodal drug injections in patients undergoing bipolar hip hemiarthroplasty. METHODS: Of eighty-two cognitively intact elderly patients about to undergo bipolar hemiarthroplasty after a hip fracture, forty-three were randomly assigned to receive preemptive pain medication and intraoperative periarticular injections (Group I) and thirty-nine were assigned to not receive preemptive medication and injections (Group II). These two groups were compared with regard to the pain level on postoperative days one, four, and seven; at discharge; and when they started walking and standing exercises. Total amounts of fentanyl used, the frequency of use of patient-controlled analgesia, patient satisfaction at discharge, and perioperative complications were recorded. RESULTS: Group I had a lower pain level than Group II on postoperative days one and four, but no intergroup difference in pain level was observed on postoperative day seven. The total amount of fentanyl used and the frequency of use of patient-controlled analgesia were also lower in Group I. Patient satisfaction at discharge was higher in Group I. No significant intergroup differences were found in the times until the patients walked or performed standing exercises or in the complications. CONCLUSIONS: Multimodal pain management provides additional pain relief until the fourth postoperative day, improves patient satisfaction at discharge, and reduces total narcotic consumption for postoperative pain management after hip hemiarthroplasty for hip fractures.

A long-term outcome of therapeutic angiogenesis by transplantation of peripheral blood stem cells in critical limb ischemia after interventional revascularization.

A 61-year-old male patient with atherosclerotic critical limb ischemia in the left leg underwent stent insertion into the left superficial femoral artery. Stenting procedures improved Rutherford grade from III-5 to II-4. Granulocyte colony-stimulating factor stimulated the production of white blood cells over four-fold and mononuclear cells (MNCs) 1.5-fold in the whole blood. Transplantation of 7.9x10(9) autologous MNCs into the left femoral artery rapidly decreased the leg pain intensity, with further improvement of Rutherford grades from II-4 to 0-0 without any side effects. In the four-year follow-up, significant improvement was found in terms of ankle brachial index, from nondetectable to 0.67, and peak systolic velocity, from 14.8 to 36.1 cm/s. Limb salvage and decreased resting pain were the notable outcomes of the treatment.

Incarceration of a dislocated mobile bearing to the popliteal fossa after unicompartmental knee arthroplasty.

The mobile meniscal bearing of unicompartmental knee arthroplasty is completely free moving, and dislocation of this bearing is a major concern for all mobile-bearing designs. Most dislocations are located in the intracapsular area; however, posterior dislocation of the polyethylene bearing to an extra-articular area of the knee after unicompartmental arthroplasty has not been previously reported. During a revision surgery, separate incision was necessary to remove a dislocated meniscal bearing in the popliteal fossa. The authors present a case of incarceration of a dislocated mobile bearing to the popliteal fossa after unicompartmental knee arthroplasty that was missed during initial diagnosis.

Combination immunotherapy of MAb B6.1 with fluconazole augments therapeutic effect to disseminated candidiasis.

We recently reported that IgM MAb B6.1, specific for ß-1, 2-mannotriose on the cell wall of Candida albicans, is therapeutic to disseminated candidiasis due to C. albicans. In the current study, we examined if MAbB6.1 enhances therapeutic effect of fluconazole (FLC) to the disseminated disease. To assess the combination effect, determination by the kidneys-colony forming unit and survival times were used. Results showed that the therapeutic effect of FLC on mice with disseminated candidiasis was dose-dependent, but a FLC dose at 0.8 mg/kg body weight of mice was ineffective. To determine combination effect, mice treated intraperitoneally with a combination of FLC plus MAb B6.1 at 1 h post-infection - a condition of developing partial therapeutic activity - enhanced survival times beyond the effect by only antibody (p < 0.05). The resulting MST (mean survival times) value from the combination-received mice was almost the same as MST value from 3.2 mg FLC dose-given animals (p < 0.05). Another combination of 1.6 mg FLC dose and B6.1 reduced severity of the disseminated disease at almost the same rate as combination efficacy of 0.8 mg FLC dose plus B6.1. This data indicates that B6.1 acts in concert with FLC and that this combination therapy augments protection, which suggests a possibility of reducing FLC dose. The augmentation response was specific because an irrelevant IgM MAb S9 was not effective to the disseminated disease. Thus, our present studies demonstrate that this combination immunotherapy may be a way of solving the problem of limited antifungal drug choices caused by drug-resistant C. albicans.

Combined posterolateral corner reconstruction with remnant tensioning and augmentation in chronic posterior cruciate ligament injuries: minimum 2-year follow-up.

PURPOSE: To evaluate functional results and knee stability after tensioning of remnant posterior cruciate ligament (PCL) with anterolateral (AL) bundle reconstruction and posterolateral corner (PLC) reconstruction in chronic PCL and PLC injuries. METHODS: Between March 2001 and March 2007, 95 patients with chronic PCL injuries combined with PLC injuries underwent tensioning of the remnant PCL with AL bundle reconstruction and PLC reconstruction. Among these 95 patients, 70 who were satisfied with our inclusion were reviewed. The mean follow-up period was 40.1 months (range, 24 to 96 months). Tensioning of remnant PCL fibers was performed by distal transfer of the posterior tibial attachment. The AL bundle of the PCL was reconstructed by use of the modified inlay technique. The PLC reconstructive procedure was performed with a single sling through fibular tunnel. Stability was measured on posterior stress radiographs and by use of a maximal manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee and Orthopädishe Arbeitsgruppe Knie scoring systems were used for clinical evaluation. RESULTS: Stress radiographs showed that the mean side-to-side difference (posterior tibial translation compared with that of the contralateral knee) was reduced from 10.3 ± 2.4 mm preoperatively to 2.2 ± 1.5 mm at the last follow-up (P < .001), whereas the KT-1000 tests showed that this difference was reduced from 8.4 ± 2.2 mm preoperatively to 2.0 ± 1.4 mm (P < .001). The final International Knee Documentation Committee objective score was A in 30 patients (42.8%), B in 34 (48.6%), and C in 6 (8.6%). The mean Orthopädishe Arbeitsgruppe Knie score improved from 63.5 ± 10.4 to 88.9 ± 7.6 (P < .001). CONCLUSIONS: Excellent posterior stability and relatively good clinical results were achieved with tensioning of the remnant PCL and AL bundle and PLC reconstruction by use of fibular tunnel for patients with chronic combined PCL-PLC injuries. LEVEL OF EVIDENCE: Level IV, case series.

Posterior epidural fibrotic mass associated with Baastrup's disease.

A few reports have demonstrated rare cases of Baastrup's disease that involve epidural cysts that cause dural compression. However, there have been no reports of a midline epidural fibrotic mass being associated with Baastrup's disease. A 60-year-old man presented with neurogenic claudication that had lasted for 5 years. Radiography showed anterolisthesis at the L4-L5 level, magnetic resonance imaging demonstrated severe stenosis due to a posterior noncystic mass, and the linear fluid signal tracked into the posterior epidural space at the L4-L5 level. A cleft in the ligamentum flavum was identified by probe at surgery, and this enabled the probe to be inserted into the epidural space without excising ligamentum flavum. Histological analysis showed that the fibrotic mass consisted of a collagen matrix that had a cystic component and exhibited a peripheral inflammatory reaction. This report shows that it is possible for an extended epidural cystic mass that occurs in Baastrup's disease to change over time through peripheral inflammation into a cyst-containing fibrotic mass.

Liquiritigenin, a licorice flavonoid, helps mice resist disseminated candidiasis due to Candida albicans by Th1 immune response, whereas liquiritin, its glycoside form, does not.

Licorice (the root of Glycyrrhizae plant) has been used as an oriental herbal medicine for thousands of years. The licorice flavonoid components are reported to possess immunomodulatory activities. In this present study, we investigated the immunomodulatory effects of liquiritigenin (LG) and liquiritin (LQ), licorice flavonoid components, against disseminated candidiasis due to Candida albicans, a dimorphic fungus, that causes severe disease via hematogenous dissemination and local diseases such as vaginitis and thrush. Results showed that direct interaction of LG or LQ with C. albicans yeast cells resulted in no growth-inhibition, in vitro. When tested in a murine model of disseminated candidiasis, mice given LQ intraperitoneally before intravenous challenge with live C. albicans yeast cells had similar mean survival times (MST) as untreated mice groups. On the contrary, mice given LG in the same manner as LQ above had longer MST than the untreated mice groups (P < 0.05). In one experiment, 3 out of 5 LG-treated mice survived during the entire period of the 55-day observation. Furthermore, the 3 survivors were cured -- shown by a lack of CFU (colony forming unit) in the kidneys. This protection was nulled when mice were pretreated with anti-CD4+ antibody before LG-treatment and challenge with the yeast. However, the protection was transferable by the CD4+ T cells isolated from LG-treated mice not infected with the yeast. In addition, mice given CD4+ T cells that were pre-treated with LG, in vitro were also protected against disseminated candidiasis. ELISA analysis revealed that in LG-treated mice IFNgamma and IL-2 were dominantly produced compared to IL-4 and IL-10. When LG-given mice were treated with anti-mouse IFNgamma, the protection was again nulled. Combined together, these results indicate that LG protects mice against disseminated candidiasis by the CD4+ Th1 immune response.

Observer variability in the evaluation of multiple lumbar stenosis by routine MR--myelography and MRI.

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine whether magnetic resonance myelography (MRM) improves the evaluation of the severity of stenosis in patients with multilevel lumbar stenosis. SUMMARY OF BACKGROUND DATA: MRM shows a similar image as myelography in a noninvasive manner. METHODS: One hundred patients over 50 years of age with multiple lumbar stenosis who were prospectively referred for MR imaging (MRI) with MRM were enrolled in the study. The most severe stenotic segment and the degree of stenosis of that segment, as assessed by the extent of remaining subarachnoidal space (1: normal to 50%; 2: over 50% but not a total blockage; 3: total blockage) were evaluated in a blinded manner by 2 observers. Conventional MRI (class A), MRM (class B), and MRI combined with MRM (class C) were evaluated independently and interobserver and intraobserver reliability were assessed. RESULTS: In the selection of the most severe segment and degree of stenosis, for both observers, the consensus between class (B) and class (C), was higher than that of class (A) and class (C). The average kappa values for interobserver agreement in the selection of the most severe segment/assessing the degree of stenosis for classes (A), (B), and (C) were 0.649/0.727, 0.782/0.771, and 0.832/0.784, respectively. Intraobserver kappa values were also highest for class (B), followed by class (C), and then class (A). Observations were within the range of "almost perfect" (0.81< or =kappa< or =1), with the exception of the selection of the most severe segment in class (A) by one of the observers. CONCLUSIONS: When employed in routine practice, MRM could be of value for improving observer reliability in the assessment of severity of stenosis in multiple lumbar stenosis.

Transradioulnar single Kirschner-wire fixation versus conventional Kirschner-wire fixation for unstable fractures of both of the distal forearm bones in children.

The purpose of this study was to introduce transradioulnar single Kirschner-wire (K-wire) fixation technique for unstable fractures of both of the distal forearm bones in children and to evaluate the differences in clinical and radiographic results of osteosynthesis between this method and conventional K-wire fixation. Forty-one patients (20 conventional K-wire fixation, 21 transradioulnar single K-wire fixation) were reviewed who underwent a closed or mini-open reduction with K-wire fixation for fractures of both of the distal forearm bones. Their mean age at operation was 10.7 years (range, 8-16 years). Surgical intervention was indicated (1) when in addition to a complete ulnar fracture, the radius showed a 50% of displacement or greater, or 20-degree angulation or greater, (2) when in addition to an incomplete ulnar fracture, the radius was completely displaced, and (3) when reangulation was 15 degrees or greater in any direction at follow-up. The minimum follow-up period was 2 years. Bony union was achieved in both groups at approximately 7 weeks after surgery, and there were no significant differences in the operative time, duration of hospitalization, and duration of external support between the 2 groups. There were no major complications such as nonunion, radioulnar synostosis, premature physeal closure, or redisplacement or reangulation. Transradioulnar single K-wire fixation technique was a relatively simple procedure with comparable outcomes compared with conventional K-wire fixation technique. In addition, physeal injuries could be avoided, and there was no need for passing across the fracture line. Thus, it is suggested that transradioulnar single K-wire fixation technique can be a good alternative method for high-risk fractures of both of the distal forearm bones in children.

Transplanted bone marrow cells localize to fracture callus in a mouse model.

Bone marrow contains many cellular elements that may contribute to fracture repair. We used a pluripotential stromal cell in a mouse model to demonstrate the presence of transplanted cells in fracture hematoma and subsequently in maturing fracture callus. Cells were transduced with traceable genes (lac Z and neomycin resistance) and traced in vivo after intravenous injection into syngeneic mice. These transduced cells home to bone marrow, suggesting that they might be detected in fracture callus. Cells were injected intravenously into mice and stabilized femoral shaft fractures were induced. Control mice received intravenous lactated-Ringer's solution prior to fracture. Callus tissue and marrow were examined histologically from I to 10 weeks after fracture to detect transplanted cells. Transplanted cells were detected in fracture callus in areas, and at times, of most active bone formation. Control specimens showed minimal staining of the callus tissue. Levels of the traceable gene in fracture callus increased, reached a peak between 3 and 4 weeks after fracture, then diminished and disappeared by 10 weeks post-fracture as woven bone at the fracture site was replaced by lamellar bone with cells from the host mouse. The results show that pluripotent bone marrow cells home to the marrow after systemic injection and localize in fracture callus.